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Prescription puzzles

There is a problem with overprescribing of opioids but is it partly to do with the law of unintended consequences, says our correspondent…

 

 

An old acquaintance came into the pharmacy one Monday in May. She was using a crutch and looked a little uncomfortable. She is not a regular patient and if she was on repeat medication, her prescription was not being dispensed by me.

I would not describe her as a close friend but many years ago our children were in the same class at primary school and we used to chat outside the gate in the afternoons while we waited for the urchins to emerge.

Instead of handing over the item for dispensing, she asked if she could have a word and slapped a script for 112 oxycodone 10mg tablets on the counter. Before I could say anything she asked outright: “Am I going to get addicted if I take these?”

It turned out that the week before she had been in hospital for a knee replacement. She had opted for a private hospital that does knee and hip replacement operations for the NHS. She had been sent home with three days of pain relief medication (oxycodone) and advised to switch to paracetamol after that if the pain persisted.

Well, the pain did persist, so she decided to phone up the surgery and ‘ask for a prescription.’ She had spoken to a GP and was told she could pick up a script from the receptionist later in the day. I didn’t get to the bottom of exactly how the conversation with the GP went but got the impression she had asked for a prescription for paracetamol.

But doctors don’t prescribe paracetamol anymore for self-limiting musculoskeletal pain because they know it is one of the conditions for which OTC items should not routinely be prescribed. It was ok, though, to write someone up for 56 days of treatment with oxycodone as an alternative! Not breaching any CCG guidance there!

But my old friend had been listening to the radio while she had her leg up, and particularly a File on 4 programme on the Sunday afternoon entitled ‘Opioids: a painful prescription?’ It had taken the pharmaceutical industry to task over some questionable marketing practices and asked whether this had helped fuel the UK’s opioid addiction crisis.

She had made the connection between opioids and her discharge medication, and done her homework on the internet, perhaps too well. She had hit on a US site called AddictionCenter which she insisted I call up on the dispensary computer.

‘Oxycodone addiction,’ trumpeted the page header, followed by ‘Oxycodone is a powerful painkiller and one of the most commonly abused prescription drugs in the country…the transition from abuse to addiction can be a quick and dangerous road.’

Then the following day she was being prescribed a further six weeks of ‘one of the most addictive drugs available by prescription.’ No wonder she was alarmed!

There are a number of lessons here. The first is that people now instinctively turn to their GP for a prescription – even for cheap-as-chips stuff like paracetamol. If they are over 65 they don’t have to pay, do they? It is going to take some time to wean people off this habit.

The second is that caving in to patient demands and prescribing a powerful analgesic in order to avoid breaching CCG guidance is not good clinical practice. GPs are going to have to be more independent in their decision-making or say ‘no’ more often – and I know that isn’t always easy.

But anyway, opioids are not first-line therapy for chronic non-malignant pain. And why 56 days? Surely your averagely well-informed GP must be aware that there is a rising tide of concern about the rocketing number of prescriptions for opioid painkillers.

Compared to the USA, the UK’s problems are minor, although File on 4 (I have since listened to the programme on BBC Sounds) did quote research from the BMJ which indicated that up to a £100 million a year could be being wasted by GPs over-prescribing opioids for musculoskeletal pain.

But it looks like the government is acting in a timely manner on this issue at least. Back in April the health secretary Matt Hancock announced that all opioid medicines will be required to carry prominent warnings about the risk of addiction.

This is an early output from an expert working group of the UK’s Commission on Human Medicines which started an independent review of the use of opioid medicines back in February. It is specifically considering the benefits and risks of opioid-containing medicines, taking into account alternatives. So watch this space.

In the meantime, can I recommend a toolkit created by a team at the University of East Anglia School of Pharmacy which has developed a toolkit to help GPs wean patients off opioids being taken for chronic non-cancer pain. Go to http://www.uea.ac.uk/pharmacy/research/chronic-opioid-use-in-non-cancer-pain if you are interested.

Penalty charges – a growing business?

I must confess to being surprised at the magnitude of the losses the NHS estimates it is incurring from people incorrectly claiming exemption from prescription and dental charges – some £212 million in 2017-18 according to a recent report from the National Audit Office.

It seems the NHS BSA has developed a successful small business in issuing penalty charge notices (PCNs) to offenders. It might be spending £11.2 million a year managing the process, but at a cost of 31p per £1 recovered, it is certainly a profitable one. The number of prescription checks reached a staggering 24 million last year with one in 20 resulting in a PCN.

However, dig a little deeper and you will be on more familiar turf. The rules around entitlement are overly complicated, leading to genuine mistakes and confusion for many people, acknowledges the NAO. You only need to spend an hour or two taking in scripts at the dispensary counter to realise that. I get pretty confused myself sometimes.

The NAO report lists some classic examples. Under universal credit, claimants are only eligible for exemptions if their monthly earnings are below a specified level, for example. And while a claimant who receives income-based jobseeker’s allowance is automatically eligible for free prescriptions and dental treatment, a claimant who receives new-style jobseeker’s allowance or contribution-based jobseeker’s allowance is not. And a person’s eligibility for exemption may vary between prescription and dental treatments, and so it goes on.

You also have to wonder just how effective the NHS BSA’s checking process is. Since 2014 around 1.7 million PCNs - 30% of those issued - have subsequently been withdrawn because a valid exemption was confirmed to be in place. The NHS BSA is trialling a real-time exemption checking process in a few pharmacies. It is certainly a step in the right direction but if the error rate is 30% it has the potential to cause more problems for pharmacy staff than it solves.

At the moment we rely on patients being honest (or confused) and accept in the main what they tell us when claiming exemption. But what if the RTEC system tells us something different? This could take the policing of exemption checks to a whole new level.

According to the PSNC, if the patient believes they are exempt from prescription charges but RTEC returns no exemption information, the patient will complete a declaration on an EPS token in the normal way. That will help avoid confrontation but I can still envisage some awkward conversations.

There is, no doubt, a hardcore of persistent exemption claim offenders and the NHS BSA is now targeting people who have received five or more PCNs in a 12-month period and made no attempt to pay.

Sir Amyas Charles Edward Morse, KCB, comptroller and auditor general of the NAO, sums it up nicely from the comfort of his lofty office: “Free prescriptions and dental treatment are a significant cost to the NHS, so it is reasonable to reclaim funds from people who are not exempt from charges and deter fraud. However, the NHS also needs to have due regard to people who simply fall foul of the confusing eligibility rules. It is not a good sign that so many penalty charge notices are successfully challenged.”

Quite so.

Finally there is nothing like a good quote to encapsulate a pearl of wisdom, especially when it comes from a politician. I came across this one recently from Tony Abbot, the former Australian prime minister, that’s right up there. “No-one, however smart, however well educated, however experienced, is the suppository of all wisdom.”

 

 

Withering's Wisdom is the pen name of a practising independent community pharmacist. Withering’s views are not necessarily those of ICP.

 

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